33 - Renal Transplantmmmmmmmmmmmmmmmation.pptx

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1. Renal Transplantation Indications, pt selection & preoperative preparation Presenter: Dr Nuru B (USR IV) Moderator: Dr Mequanint (Consultant Urologist)

2. Outline Historical background Introduction Indications of Renal Transplantation Preoperative preparation Recipient Donor Deceased Living Immunologic compatibility References

3. Historical background 1902(Ullmann) First successful experimental kidney transplant 1906( Jaboulay ) First human kidney transplant—xenograft 1933( Voronoy ) First human kidney transplant—allograft 1950 Revival of experimental kidney transplantation 1950–1953 Human kidney allografts without immunosuppression, in Paris and Boston 1953 First use of live related donor, Paris 1954 First transplant between identical twins, Boston 1960 First case of successful chemical immunosuppression. . Mathieu Jaboulay (1860-1913) Voronoy (1895–1961)

4. Dialysis Types: HD and PD Transplantation Advantages Better long term survival Better quality of life More cost effective It’s drawbacks Major operation SE and cost of immunosuppressive drugs Half-life of kidneys is on average 10yrs Why renal transplantation??

5. Anemia Cardiovascular risk Vascular calcification Quality of life Cost Infections Malignancy Clinically-Relevant Outcomes of ESRD Txs

6. Indications Potential candidates Renal transplantation should be discussed with all patients with advanced CKD with NO absolute contraindications. eGFR < 30 If initial RRT is expected within 12 months Pts on chronic dialysis Renal neoplasia All transplant candidates Should undergo pretransplant evaluation Should be capable of surviving the current waiting time Should have reasonable expectancy Should have an expected greater quality of life after the procedure.

7. Preoperative preparation Counselling and informed consent Recipient evaluation Donor evaluation Immunologic compatibility

8. Counselling and Informed C onsent May involve professional counselors Nature of the disease and the need for transplant Outcome and complication Need for compliance to immunosuppressive therapy Other available options

9. General assessment History and physical examination Lab investigation Imaging evaluation Immunologic evaluation Recipient evaluation

10. Cardiac Cardiac disease is the single largest cause of mortality in both the dialysis and transplant populations Almost always treat treatable conditions before transplantation Combined heart and renal transplantation in severe and irreversible cardiac dysfunction Recipient evaluation Pt group Assessment All patients Hx , P/E, ECG and CXR Asymptomatic, high risk Stress ECG, Echo, or myocardial perfusion study Symptomatic, significant risk factors OR + ve screening test Coronary angiography

11. Vascular Iliac vessels must be assessed Preexisting peripheral vascular disease CVA TIA Berry aneurysms Recipient evaluation

12. Respiratory Pre-op asst Should be the same as for the general population. Contraindications Uncontrolled asthma Severe cor -pulmonale Severe COPD Recipient evaluation

13. Hepatic Disease Hepatitis B HBsAG , anti-HBc and anti-HBs Liver histology Posttransplant Entecavir Is not a C/I to renal transplantation, but cirrhosis Hepatitis C Limitations of DAA in pts with ESRD Glecaprevir + Pibrentasvir Pretransplantation vs posttransplantation treatment Other liver disease Alcoholic liver disease, Polycystic liver ---in ass with APKD Cholelithiasis -- ? prophylactic cholecystectomy Fatty liver disease ----- ?DM Severe liver disease--- regardless of cause inhibits graft acceptance Recipient evaluation

14. Infectious disease Vaccination strategies Obtain vaccination hx and correct deficiency Vaccination after transplantation Contraindicated(absolute) with live vaccines May fail with killed antigen vaccines HIV Outcome is acceptable in short and mid-term HIV+ donor to HIV+ pts in high prevalence areas The accepted criteria for listing HIV+ patients include Stable CD4+ T cell levels >200/ μL Compliant on HAART with HIV RNA undetectable Without opportunistic infection Posttransplant potent drug interactions Other Viral Infections—CMV, EBV, HHV6/7, HHV8 All patients should be tested for antibody status with respect to each of the herpes viruses. Dental Ensure adequate dental hygiene and review of dentition before acceptance Recipient evaluation

15. Malignancy There is a clear and defined additional risk of malignancy Cancer-free period of 2 to 5 years There is no specific guideline for cancer screening Advice pts about cancer risk and available screening guidelines Recipient evaluation

16. Psychiatric disease and drug dependency Compliance after transplantation Noncompliance is one of the causes of graft loss Psychological stress of transplantation Abstinence from chemical dependency is essential Bone Normalize the Ca x Pi to minimize: Hyperparathyroidism, Osteoporosis, and Vascular calcification after transplantation.  Recipient evaluation

17. GI tract Active PUD - low dose or complete avoidance of steroids + PPIs GERD, malabsorption syndromes, celiac disease, diverticulosis, and cholelithiasis Recipient evaluation

18. DM Type 1 DM SPK transplant ~ Half of T1DM recipients are suitable Is more demanding with added morbidity Has many benefits Type 2 DM Presents challenge Only small proportions of pts are suitable for transplantation Recipient evaluation

19. Renal disease Recurrent Renal Disease Distinguish between risk of recurrence and prognosis of the graft after recurrence Living-related transplantation should be used with caution in some conditions Recipient evaluation

20. Urogenital Tract Abnormalities Candidates with Recurrent UTI VUR BOO Bladder dysfunction Abnormal prostate exam and Other voiding patterns Need further urologic evaluation and intervention before transplantation. Native Nephrectomy Chronic renal parenchymal infection Infected urolithiasis Refractory hypertension Heavy proteinuria Polycystic kidney disease with massive nephromegaly VUR with complications Primary hyperoxaluria Suspicious renal masses Recipient evaluation

21. Coagulation Disorders Recipient evaluation

22. Obesity Is associated with new onset DM In obese children it’s associated with graft failure. Increased risk of wound infection But higher in malnourished. Weight reductions options Shifting from peritoneal dialysis to hemodialysis Lifestyle changes Bariatric surgery Recipient evaluation

23. Sensitization and Transfusion Status Previous transfusion Pregnancy Previous allograft Previous Transplantation Retransplantation – is less successful Renal graft loss is increasing Nonrenal organ transplants requiring a renal transplant is increasing Transplant nephrectomy Recipient evaluation

24. Active malignancy Active infection Severe irreversible extrarenal disease Life expectancy <2 years Liver cirrhosis (unless combined liver and kidney transplant) Primary oxalosis (unless combined liver and kidney transplant) Limited, irremediable rehabilitative potential Poorly controlled psychiatric illnesses Active substance abuse Active peptic ulcer disease a Medical noncompliance Active hepatitis B virus infection b Morbid obesity Contraindications Absolute Contraindications Relative Contraindications Special Considerations ABO incompatibility c Positive T-cell crossmatch

25. Living donors Living related(LRD) Living unrelated (LUD) Good Samaritan/Altruistic donors Paired exchange donors Deceased donors Brain dead donors (DBD Cardiac death donors (DCD) Types of Donors

26. A multidisciplinary approach Independent living donor advocate, Nephrologist, Surgeon, Social worker, Medical psychologist, Financial counselor. Category Medical history and P/E General health laboratory and focused renal, immune;ogic and infectious Age-appropriate health and cancer screening Cross sectional imaging Living Donors evaluation Medical evaluation

27. Living Donors evaluation

28. Surgical evaluation Assess operative risk of the donor Laparoscopic nephrectomy Primary surgical approach to living kidney donation Discussion on technical aspect of surgery Immediate complications Discharge and follow up Recovery and functionality Rehospitalization and renal failure Living Donors evaluation

29. Living Donors evaluation

30. Living Donors evaluation ESRD… 7-11 fold Proteinuria… 6.1% ↓GFR… 30% HTN…. 21% Postdonation non-ESRD risks- ?associations Cardiovascular Pregnancy Rehospitalizations ???Mortality Long-Term Outcomes After Living Donation

31. Deceased Donor types Donation after brain death (DBD) Standard criteria donors (SCD) Under 50 years, any cause Expanded criteria donors (ECD) Over 60yrs old OR 50-59yrs old with at least 2 of the following Hypertension CVA cause of death Preretrieval Serum Cr >1.5 mg/dL Donation after circulatory death (DCD) Controlled DCD Uncontrolled DCD

32. ABO compatibility Immunologic compatibility

33. HLA compatibility HLA – human equivalent of MHC A group of highly polymorphic cell surface molecules that act as recognition unit by T- Lymphocytes HLA class I – HLA-A, B, C ( present in all nucleated cells) HLA class II – HLA-DR, DP, DQ ( present in B,T and APCS) HLA – A, B & DR are most important in renal transplantation Immunologic compatibility

34. Inheritance of HLA haplotypes Immunologic compatibility

35. Allorecognition Immunologic compatibility Direct Cytotoxic T cells from the recipient bind directly with foreign HLA antigens on cells of allograft and release cytotoxic factors Indirect Host APC’s present foreign MHC antigens on graft cells to recipient T helper cells

36. Tissue Typing and matching To determine the HLA type of blood for both donor and recipient by PCR Lymphocyte cross matching to exclude circulating antibodies in the recipient against HLA expressed by donor HLA antibody screening and specificity in recipient before and after transplant to guide immunosuppressive therapy Immunologic compatibility

37. References